Treating Movement Disorders With Telemedicine: Getting Started

My name is Jamie Hatcher-Martin — I am an assistant professor of neurology at Emory University and my specialty is movement disorders.

My interest in telemedicine started because a lot of patients, due to either movement difficulties or due to cognitive impairment, either are unable to drive or have difficulty driving, and so a lot of them had trouble getting to our clinics, whether they were local, or it was even worse for other patients that live remotely. Many of them were traveling 3 to 4 hours each way, and so a lot of times they would actually come in the night before and have to pay for a hotel, just to be able to make their appointments, and for a lot of Parkinson’s patients, these long trips were often very hard for them. They had a lot of stiffness, a lot of trouble with that, and especially if they have cognitive impairments, sometimes staying the night, you know, long rides in the car or staying the night in a hotel would often trigger trouble with cognitive impairment.

So that’s really where my interest came initially. After paring down some ideas and working out some things, I approached administration about trying to start a telemedicine program and everybody I talked to said, “Well, there’s so many different ways you could do it.” And so for us, I tried to start something that was relatively easy and within the network that we had already.

So I went through all of our satellite clinics and found the locations that were actually considered rural from a telehealth reimbursement standpoint, and once we identified those clinics, it made it easier — I was already faculty, so credentialing was easier — just had to do another site credentialing on a different location.

Billing was easier, and so we started looking at how many patients were in that area that would be in that catchment area, and we just started with a pilot first. We just did several clinics, and we got patients that, you know, I just told them about it. Anytime we looked at all of the patients that were in that area, and just called and said, “Hey, would you be interested in participating in this? We wanted to see if, because you’re in a rural area we can bill. We wanted to see would we get reimbursed? Did it matter if it was Medicaid or Medicare or private insurers?

So we ran a pilot first, and that worked out well, and we got paid by everybody, which makes administration happy. So we got the go-ahead and we’ve since opened, doing just 1 morning a week right now, and it’s actually been really successful! Patients are starting to seek us out because they’ve heard about a telemedicine program — we didn’t have to sell it to people too much. A lot of them are very excited to have the opportunity and not have to drive all the time. I even have some patients that live on the outskirts of Atlanta that would actually rather drive 40 miles out to a telemedicine visit rather than 20 miles through Atlanta traffic, so there’s been a lot of interest, and so far we’ve gotten really good feedback.

The biggest thing is, it’s worth just spending some time playing with it — I started out before we even did the clinic. I picked a few patients and said, “Hey, would you be interested in just trying this out?” and I just spent some time playing with the software — so we actually had a program where we had a license with the program, and so I started with that one. I would always tell people, “It you’re at an institution, then talk to them about what source software conferencing programs they already have.” If not, there’s a whole list of things that are available — but just spend some time and get to know it.

It was nice because I went through and I installed it on my Mac, and I have a PC and I did on my phone, and I had my husband install it, so I was able to sort of see where some of the kinks were, and kind of figure those things out, so when patients started it and said, “I’m having trouble with this,” I could say, “Oh I had that problem too, and this is what we had to do.”

I think the daunting thing was, a lot of people said, “Well, you know, I don’t have the software…” We started out with just a cheap WebCam, and an internet connection, and that’s all we had. We didn’t have a special computer, we didn’t have a special camera. We didn’t buy one of these really expensive telemedicine carts because for what we need, it wasn’t necessary. So I would just tell people, talk to other people. I think that’s the biggest thing is, I found people to be very open and encouraging with their experience in things that maybe they had trouble with, so it sort of saved me some time by talking to others, but it’s actually been pretty seamless. Now that things are starting to pick up, we’re buying a little bit nicer of a camera, but still not very expensive. I mean, we’re certainly not doing one of these big telemedicine carts, we’ve just done it with a regular camera on the computer.

I think the biggest thing is just to be open with your patients, tell them what to expect. I always tell patients there are certain parts of the exam we won’t necessarily — so let’s say for Parkinson’s disease, we won’t test rigidity. We don’t typically do — I don’t have a telepresenter on the end so it’s just me and the patient and their family. So we don’t typically do, you know, pull testing to look for falls and things like that. But I just explain to them that this is what we are going to do, and I always tell people too, a lot of times that most of the decisions we make are based on what they’re telling us in their history and things that have been going on for the last 3 months, not necessarily this 20 minute exam. And so while the exam is helpful and helps us keep track of things over time, it’s not what we use to make all the decisions. And so I always tell people too, for a lot of us that do research, if you’re a blinded rater, let’s say for Parkinson’s disease in a research study, often we’re doing these weightings on a video that’s already been done, so I don’t even have the option of saying, “I couldn’t really see that very well, could you turn your hand a little better? Could you do that again because I didn’t get a really good visual of that.”

I think when patients start to realize that we’re doing this already, and for a lot of my patients, they’ll email me and say “Hey listen, you know, I have this movement and I don’t know if it’s a tremor or dyskinesia. And I’ll say, “Well, send me a video.” So I think we’re doing this already with our patients and I think when you start to connect those dots, and they start to realize this is just an extension of what we’re already doing, except I get immediate feedback. I don’t have to wait, you know, 12 hours for a response on the portal or I don’t have to wait 2 weeks for another appointment. I think when they start to realize that the access is much more feasible and much better, and then potentially it could avoid them having trouble with some side effects of medications or going to the ER, I think it really opens them up a lot, and I always tell them too, you know, if you think you might be interested, just try it! It doesn’t mean you have to do it all the time, it doesn’t mean you have to do it ever again. But I think a lot of patients are pleasantly surprised that you don’t really lose that interaction. I tend to be a very touchy-feely person in clinic anyway, so I was a little worried that that would get lost. But I think your personality still comes across regardless of whether you’re actually in person or just over video.

I think for a lot of providers it’s very hard to do new patient visits, because there are certain things that especially without a tele-presenter on the other end that are hard to evaluate — we can’t do rigidity, we can’t do reflexes. You can do some strength testing, sort of functional strength testing, but you can’t do the nuanced things. So unless you either have somebody on the other end, or the patient’s being referred by maybe a neurologist that you really trust their exam, I think in that sense it’s very hard to do a new patient visit. Other than that, you know, sometimes with our patients that have really soft voices, sometimes that can make things a little more difficult. But overall, and you know I always tell patients too, if there’s something that we can’t evaluate, then I’ll just have you come in. I kind of set them up that this may not be the answer to everything. I think those are probably the biggest things.

I think this is the way things are going and I think, you know, I’ve been pleasantly surprised by how quickly a lot of our older patients are adopting this, but I think the biggest thing is especially some of our younger patients that are much more tech savvy as it is. And I remember hearing somebody say at some point, you know, that the people that we are treating are changing, and so we need to change the way that we deliver care, and people are used to having anything at their fingertips, and I don’t think health care is any different.